New tool to support urgent palliative care needs being met first

When resources are limited and patients are many, how do palliative care doctors decide who most urgently needs their attention? That is a question with no standard, evidence-based answer, which has inspired a Melbourne doctor to develop a new triage tool to make access more fair and equitable internationally.

Dr Beth Russell, palliative care physician at St Vincent’s Hospital’s Centre for Palliative Care, became interested in how individuals’ palliative care needs were compared while working in regional South Australia and Victoria with patients who chose to stay at home rather than go to hospital. Her interest in equity continued when she returned to work in a large Melbourne health service, where there was also no consistent way of assessing the urgency of referrals made by different hospital departments or from external hospitals or community services.

She says while some palliative care services have systems, research has shown them to not be robust or evidence-based.

“The problem with previous triage tools is that they weren’t necessarily capturing the whole story, or overcoming the influence of people who were still trying to advocate very strongly for the patient they had personal involvement with, which is understandable.”

Dr Russell says a standardised approach is important to ensure that even the most vulnerable patients who are least able to advocate for themselves are assessed fairly, so that all patients receive the care they need in the order of urgency. Similarly, she says it is important to prevent incorrect assumptions, like that someone gradually deteriorating at home with a family carer must be in dire straits, leaving a patient with unstable pain on a surgical unit with more potentially urgent needs missing out.

“Even within one palliative care service, referral is very dependent on the relationships. So there might be a good liver team or a good flow of referrals from an oncology team, but not from [departments with patients with] non-malignant disease, who may also have patients with a high level of suffering who are reliant on referral.”

Dr Russell referred to Palliative Care Australia’s 2017-18 Pre-Budget Submission, which calls for a $35M investment in palliative care service provision over three years.

“There certainly is a resource limitation that needs to be addressed, but while we are working within that limitation how do we – in a fair and safe manner – work out whose needs are most urgent and require fast access? And for the effort we are putting in, and the dollars we are spending, how do we get the most good to the most people?”

While triage is something that emergency departments do relatively efficiently, the process is more complex in a palliative care context.

“In the emergency department at the triage desk the patient is right in front of you and you can glean a lot of information just looking at them and seeing their carer.

“If they get sicker in half an hour, you can reassess them. But in palliative care, we are getting calls from clinicians who may not be palliative care trained, telling us about patients we have never met. We are comparing their story to a patient we can see in front of us and that distance or immediacy might cloud our assessment.

“In palliative care we are looking at relieving physical and psychological suffering and meeting the needs of the carer as well as the patient, and looking at achieving patient preferences if they want to die in their own home. There are a lot of competing priorities. This is why it has been a hard nut to crack.”

Dr Russell conducted online research, recruiting 801 palliative care health professionals from around the world, in order to inform a scoring system to support doctors’ decision-making. Doctors from Australia, New Zealand, America, Europe, Africa and Asia participated, providing responses to clinical scenarios which reflected perceptions of urgency.

“We realised early on that this was not just a problem in Australia; it was a problem worldwide. There is a general push in health care for quality improvements, standardisation and person-centred care.”

The research has informed a tool which enables a patient’s details to be fed into a seven-item document, which calculates an overall score that can be used for comparison and ranking against other patients referred at the same time. The tool is in the process of being validated, before being implemented in community, hospital and hospice settings.

“We anticipate that it wouldn’t be applied rigidly, and a big part of palliative care is about being compassionate and flexible, so it is a decision-making tool and not a rigid protocol to enforce on clinical situations.

“It is not going to be perfect by any means, but we hope it will bring an efficient, transparent approach to triage, and hopefully more equity. At least we will know what we are doing, and so we will be able to measure it and reflect over time.”

Dr Russell sees potential for the tool to ease pressure on palliative care clinicians, who agonise over decisions when they can’t meet every patient’s needs.

“It’s not like those decisions are being made flippantly, but a decision made one day might be different to the next day, or in another hospital or community service. And all the literature suggests that quality care is evidence-based standardised care.

“And it means that when you are under pressure for beds in your hospital, and you have a specialist in another area saying ‘Why don’t you take this patient to a palliative care bed?’, it depersonalises it. You’re able to say ‘When we look in detail at your patient’s scores, there are two other patients whose scores are much higher, so we need to take them first and your patient is next on the list’. It makes the decisions transparent and takes the political pressure out of them.”

Dr Russell recently presented her research at the National Palliative Care Conference in Adelaide, having won the highly-esteemed Ian Maddocks Guest Lecture for the best submission by a palliative care researcher under 40 years of age.